Provider Demographics
NPI:1871807982
Name:MEDLEY PHARMACY INC.
Entity type:Organization
Organization Name:MEDLEY PHARMACY INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:573-437-3440
Mailing Address - Street 1:P.O. BOX 528
Mailing Address - Street 2:
Mailing Address - City:OWENSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65066
Mailing Address - Country:US
Mailing Address - Phone:573-437-3440
Mailing Address - Fax:573-437-6909
Practice Address - Street 1:733 W SPRINGFIELD RD
Practice Address - Street 2:
Practice Address - City:GERALD
Practice Address - State:MO
Practice Address - Zip Code:63037
Practice Address - Country:US
Practice Address - Phone:573-764-5980
Practice Address - Fax:573-764-5982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-30
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008034039332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO606398402Medicaid
MO2638293OtherNCPDP
MO2638293OtherNCPDP